A new study from the American Cancer Society has found that cancer patients living in U.S. counties with higher rates of medical debt are more likely to be diagnosed at advanced stages and face lower odds of survival.
Researchers examined more than 7.5 million people diagnosed with cancer between 2011 and 2019, drawing on the National Cancer Database and linking each patient to the share of adults with medical debt in collections in their county of residence. County-level medical debt ranged from 0% to 56%, with a median of 18%.
Patients in counties with the highest medical debt had the largest share of Stage IV, or metastatic, diagnoses and the lowest five-year survival rate. In counties with the lowest debt, 19.2% of patients were diagnosed at Stage IV, compared with 21.2% in the highest-debt counties. Five-year survival rates fell from 66.3% in the lowest-debt quartile to 58.6% in the highest.
After adjusting for patient and county characteristics, patients in the highest-debt counties were more likely to receive a Stage IV diagnosis (odds ratio, 1.079) and had a 7% higher risk of death (hazard ratio, 1.072) than those in the lowest-debt counties. The study reported a statistically significant dose-response relationship, with outcomes worsening as county debt levels rose. The patterns held across major cancer types and across socioeconomic and clinical subgroups.
The study, published in the Journal of the National Comprehensive Cancer Network, defined medical debt in collections as debt originating with a medical provider that was sent to a collections agency or an internal collections department, typically at least 180 days past due. The highest debt burdens were concentrated in Southern states and had been declining since 2015.
The researchers noted policy shifts affecting medical debt, including 2022 changes by the Consumer Financial Protection Bureau and the national credit bureaus that removed many medical collections from credit reports, and a later reversal of a rule that had excluded medical debt from those reports. They also cited 2025 federal legislation that cut Medicaid funding and allowed enhanced Affordable Care Act subsidies to expire.
